MOTOR CLAIM FORM

Retail Health Policy

a. Individual Medishield
b. Swasthay Kavach Policy

IFFCO TOKIO GENERAL INSURANCE COMPANY LTD.

Regd. Office: Iffco Sadan Saket

Home & Family Protector

Home Suvidha Policy
Trade Protector Policy
Trade Suvidha Policy
Office & Professional
Establishment Protector

To Intimate a claim Please call on Toll Free : 1800 1035 499

For Claim Details Please Contact
Monday to Friday Between 9.30 a.m. to 6.00 p.m.
Phone : 044-4963 2216
E-mail : intichennai@iffcotokio.co.in
IFFCO BHAVAN, Customer Service Centre,
4th Floor, 128, Habibullah Road,
T. Nagar, Chennai - 600 017.

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1.

Important Instructions

a.
b.

The issuance of this form is not to be taken as an admission of liability.

To be signed by the Insured(Registered Owner) of the vehicle, or where Insured(Registered Owner) is a
Partnership or Corporate Body, by an authorized signatory of such Partnership or Corporate Body along with
the office seal of the concerned organization.
Please do not leave any column unanswered.
All facts and Statements must be factual not influenced or biased in any form.
The damaged vehicle must be parked at safe place to avoid any subsequent damage/loss. The Company will
not be responsible for the same.
Please read carefully the attached list of documents required for faster processing of your claim.
All documents provided by the Insured must be Self Attested.

c.
d.
e.
f.
g.

2. Details of Policy Holder

Policy No/Cover Note : __________________________ Claim No : __________________________________
Period of Insurance : From : _____________________________ To : ________________________________
Name of the Insured :______________________________________________________________________
Phone Number (Home/Office) : ______________________ Mobile Number : __________________________
Name of Registered Owner :_________________________________________________________________
Current Address :__________________________________________________________________________
________________________________________________________________________________________
Email : __________________________________________________________________________________
Gender : Male / Female
Date of Birth : (dd/mm/yyyy): _____________________________
3. Details of Incident (Accident / Theft)
Date(dd/mm/yy) : ____________Time (a.m./p.m.) :___________Speed (km/hr)_________________________
Exact Place Where incident occurred : _________________________________________________________
Place to which the vehicle was heading for before incident :_________________________________________
Purpose for which vehicle was being used/parked at the time of incident: ______________________________
Nature & Weight of goods carried at the time of incident (Comm. Veh): ________________________________
No of people traveling at time of incident : ______________________ Is it reported to the Police ? YES / NO
Name & Address of the Police Station : _________________________________________________________
Gen. Diary/Crime No/FIR No and Date :_________________________________________________________
Name and Address of the place where Insured vehicle is parked : _____________________________________
Estimated Loss Amount (Rs.) :_________________________________________________________________

4. Details of Vehicle
Registration No :_____________________Make : _____________________Model:______________________
Date of 1st Registration : ______________________Date of Transfer (if applicable) :______________________
Name of Financier (if any):_________________________________ Colour of Vehicle :____________________
Type of Fuel :_______________ Chassis No.: _______________________Engine No.: ___________________
5. Details of Driver
Name :____________________________________ Relation with Insured : _____________________________
Address :__________________________________________________________________________________
Contact Number :__________________Gender : Male / Female

Driving License No :__________________

Issuing RTO :__________________________________ License Expiry Date :___________________________

Class : MCycle / LMV / HGV / Transport / Non-Transport

Type : Permanent / Learners

6. Please describe how the incident occurred

7. Details of Occupant /Passenger/Third Party/Property Injury

7a. Injury/Death Details:
S.
No.

Name

Address

Phone No.

In What

Capacity

7b. Third Party Vehicle/Property Details:

8. Other Insurance
Detail of other insurance policies indemnifying you or the driver in respect of above accident:

9. Past Claim History

Was any claim reported in the past on the same vehicle during current year policy ?

Nature of
Injury

10. NCB Claimed

Policy Details

Policy No

Policy
Inception

Policy
Expiry

Name of the
Insurer

Percentage(%)
of NCB Claim

Current Policy
1st Previous Policy
2nd Previous Policy
3rd Previous Policy
Undertaking
1.

I/We the above named, do hereby, to the best of my/our knowledge and belief, warrant the truth of the foregoing
statements in every respect and agree that if I/We have made any false or fraudulent statement or there be any
suppression or concealment of facts, the claim shall be forfeited.

2.

I/We have received a list of documents with this claim Form and will provide such complete documents along with the
signed Claim Form and have understood all the requirement to be fulfilled for administration of this claim. The Company
shall not be held responsible for any delay in settlement of claim due to non-fulfillment of requirements including the
submission of documents as required.

3.

I/We agree to provide any additional information/documents to the Company, if and when required.

4.

I/We hereby understand, agree and submit that No Claim Bonus (NCB) allowed to me/us under the Policy for which the
Claim is being preferred/lodged is subject to the fact that the own damage claim experience for the insured vehicle or
my/our earlier insured vehicle (in case of transfer of No Claim Bonus from earlier insured vehicle) in previous year
policy(s) was NIL. Accordingly I/We once again submit/undertake that the No Claim Bonus (NCB) allowed under the
current year Policy for the Insured Vehicle for which the Claim is preferred is based on the above NIL Claim history.
Further I/We undertake and submit that in case the basis of availing the No Claim Bonus (NCB) under the current policy is
incorrect, then the company may at its discretion impose suitable damages on the preferred claim which may include
forfeiture of all benefits on own damage section of policy.

List of Documents Required for Claim Settlement

(To be submitted to the Surveyor/Customer Service Centre)

1.
2.
3.
4.
5.
6.
7.
8.
9.

For Accident Claim

Proof of insurance-Policy/Cover note copy
Copy of Registration Book, Tax Receipt
[Please furnish original for Verification]
Copy of Motor Driving License [With original] of the
person driving the vehicle at the time of accident
Police Panchanama/FIR(In case of Third
Property damage/Death/Body Injury)
Estimate for repairs from the repairer where the
vehicle is to be repaired
Repair Bill and payment receipts after the job i
completed
Claims Discharge Cum Satisfaction Voucher
Signed across a Revenue Stamp
Documents as required by AML Guidelines
Permit, Fitness and Load Challan
(in case of Commercial Vehicle)

10.
11.
12.

Additional Documents for Theft Claims

Original Policy document
Original Registration Book/Certificate and
Tax payment receipt
Previous insurance details - Policy No, insuring
Office / Company, period of insurance
All the sets of Key, Service Booklet, Original Purchase
Invoice and Non Repossession Letter from Financier
Police Panchanama/FIR and Final
Investigation Report
Acknowledged copy of letter addressed to RTO
intimating theft and making vehicle NON-USE
Form 28, 29 and 30 signed by the insured and Form 35
signed by the Financer, as the case may be, undated and blank
Letter of Subrogation
Consent towards agreed claim settlement value
from you and financer
NOC of Financer if claim is to be settled in your favour
Blank and undated Vakalatnama
Documents as required by AML Guidelines

Additional documents in specific claims shall be intimated separately.

Insured
Name:
Date &
Place:

(Signature/Thumb impression of Insured)

Mandate Form for Electronic Transfer of Claim Payments

Insured Name :
Vehicle Registration No :
Bank Details
Bank Name
Bank Branch
Account Type
IFSC Code*

MICR Code*

Account Number
Bank Address
*Please also attach one Blank Cancelled Cheque for NEFT/RTGS Payment
Insured
Name:
Date &
Place:

(Signature/Thumb impression of Insured)

CLAIM DISCHARGE CUM SATISFACTION VOUCHER

Insured Name
Vehicle Registration No
Discharge Date
My vehicle number ________________ having been repaired to my complete satisfaction, I am henceforth taking
delivery of the same and authorise my insurer IFFCO TOKIO GENERAL INSURANCE COMPANY to make
payment of Rs ____________ to the ________________ garage in respect of my aforementioned vehicle. I also
confirm having paid Rs ________________ in lieu of depreciation, policy excess and any additional work carried
out at the garage.
I agree that this payment being made to the aforementioned garage is in full and final settlement of my claim.
I/we hereby voluntarily give discharge receipt to the Company in Full & Final settlement of all my/our claims
present or future arising directly/indirectly in respect of said loss/accident. I/We hereby also subrogate all my/our
rights and remedies to the Company in respect of the above loss/damages.

Signature/Thumb impression of Insured

Signature and Stamp of Garage